Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Let’s Not Mistake “Legal” With “Smart Business Practice”


Donner pass

By Phil La Duke 

I work in organizational development focused on worker safety and I have been employed as such for the better part of 20 years. I am essentially a safety strategy consultant, an architect, if you will, of safety infrastructures that help companies to build on the services I provide them and sustain gains in safety in a changing business environment. I say this because so many of you assume that I am primarily a safety blogger, theorist, or journalist; in short that I don’t have the standing to speak about much of anything. I realize a couple of sentences won’t sway the most ardent safety blowhards who believe that the only valid insights are theirs alone but every once and awhile I need to say it. It keeps me what passes for sane.

In this role of an architect for safety management systems custom-designed and built to fit the unique needs of a business sector, geographic location, and even site I am more frequently asked one question above all others, “What does the law say?” I am not a lawyer and frankly I don’t much care what the law says, when it comes to safety. That’s not to say I can’t recite chapter and verse this regulation or that; I can’t, but that’s not what I’m saying (I solicit the advice of one of my 5,000 plus colleagues at ERM who most often know the answer, or one of my 3,000 plus business contacts, or some other expert). I don’t care what the law says because I know what the business requires and often doing the bare minimum to achieve compliance does scare little in the way of smart business. Of course I care that my clients are at a minimum compliant, but let’s face it, compliance isn’t enough to smartly manage safety.

Three weeks ago I drove from San Francisco to Reno through the Donner Pass (the site where the Donner Party were stranded one winter and resorted to cannibalism. I really wanted to stop and get something to eat there but alas couldn’t find a suitable cannibalism-themed eatery.) The speed limit was 70 mph meaning that vehicles have a legal right to traverse the treacherous incline at a pretty high rate of speed. Legal? Yes; smart? No, at least for me (a man who doesn’t drive that well and who is unfamiliar with the route). The next day I was driving the congested expressways in San Francisco and Sacramento, California. In California it is legal for motorcyclists to zip between the lanes in traffic (usually at a high rate of speed) dangerously close to vehicles as they creep along. I personally witnessed several instances where cyclists engaged in such activity narrowly and miraculously avoided injury. They exercised there legal rights, but at least from where I sat, extremely poor judgment.

In my home state of Michigan, the last couple of years have seen decades of safety legislation systematically dismantled. We now allow fireworks in the hands of drooling idiots and motorcyclists are no longer required to wear helmets, legal? Yes. Smart? Absolutely not. I won’t argue the merits of the safety of wearing a helmet while traveling 120 miles an hour with a rocket on your crotch or one’s God-given right to blow off your finger with a M80, but I do think the point worth making is that just because something is legal doesn’t make it the right thing to do, morally ethical, or a smart thing to do, but many companies manage safety as if these things are synonymous.

I have met a fair amount of safety practitioners (someone about two months ago challenged me to stop calling them “safety professionals”) who will defend the practice of managing to compliance. Their reasoning tends to hinge on the fact that if it’s good enough for the Feds than it should be good enough for me; well it’s not. There are plenty of organizations that operate under substantial risk and yet to compliance programs like VPP as proof of having climbed the safety mountain. It’s a bit like the degenerate gambler who has a “system” for beating the casino. He will point to a pile of winnings as proof that his system can’t lose; until it does.

Compliance is important; but for me the lack of compliance is a merely a symptom of a larger problem, an inability to appropriately manage operations. Aspiring to comply is to aspire to mediocrity it’s akin to shooting for a D instead of an A, and while we may not all want to be world-class in safety, I’d like to think that very few of us want to do just barely enough to squeak by.

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Out of Focus: Is the Safety Function Focusing On the Wrong Things?


Out of Focus

By Phil La Duke

Since the advent of the Safety function, it’s been borrowing tools from other disciplines and building practices based on data gleaned from the earliest research in industrial psychology. For some, these most basic practices and methods are cherished and to suggest that any change to these is tantamount to heresy. For others, change may be possible, as long as we acknowledge that these practices are the cornerstone of the safety function and that they are necessary to some degree. While it’s true that in broad strokes we probably should retain some of our practices the philosophy that drives everything we do must change at a fundamental level.

The focus of safety for 100 years has been a centered around obsessions: obsession with eliminating injuries, changing worker behaviors, and identifying root causes of injuries. Simply put, this focus is wrong.

Obsessed With Preventing Injuries

Focusing on eliminating injuries is reactionary and treats symptoms. If we believe that our purpose as safety practitioners is to eliminate injuries we will find ourselves forever playing catch up, and what’s more, even if we achieve zero injuries most of us won’t really know whether this result is the product of hard work and sound safety practices or dumb luck.

Instead of focusing on injury reduction (an outcome) we need to focus on risk mitigation and severity reduction. In a discussion forum, someone asked the question “what is the behavior ‘safety’?” It’s a ridiculous question because safety isn’t a behavior; one does not “do” safety. Safety is an outcome and absolute safety, i.e. the absolute absence of risk of harm, is unachievable. Pursuing an unachievable goal is absolutely insane; you will merely frustrate your organization. But reducing the risk of harm to the lowest practicable level is achievable. We can, at least in many (perhaps most) workplaces lower the probability and severity of injuries below the threshold where injuries are no longer common and crippling but rare and minor. Our outcome (reduction of injuries) is the same but our strategies and tactics are focused not on the outcome but the causes (workplace risk factors).

Obsessed With Behaviors

Another object of fanatic obsession is “behaviors”; somewhere along the way, safety practitioners seized on the idea that the key to worker safety lie in modifying worker behaviors. Change the way the worker behaves, conventional thinking holds, and you can create a safe workplace. To be sure there are plenty of workers doing stupid things that get them hurt, but the obsession with behaviors assumes that worker behavior is a) a conscious and deliberate choice, b) something that can be changed through basic behavioral modification, and c) intrinsically safe or unsafe. We know that most behavior is not conscious, and is in fact subconscious habit, unintended behavioral drift, contextual, and difficult to change even when the individual desperately wants to behave differently. Additionally, far too many behavior-focused initiatives depend solely on psychology and ignore behavioral sciences that focus on behavior of populations (sociology, anthropology, et al) so focusing on individual behavior will force us to draw specious conclusions that feel right but that ultimately lead us far afield. Instead of focusing on behaviors we should be focusing on decision-making and problem solving. Instead of trying to change behaviors we should be focusing on building decision-making and problem-solving skills. If workers are able to make better decisions (which drive safer behaviors) and solve problems more accurately (instead of improvising when a problem prevents them from doing the job as designed) we are again able to reduce workplace risk and in turn reduce worker injuries.

Obsessed With Finding  Root Causes

The third obsession of safety professionals is finding the root cause of injuries and near misses. This focus on finding a single “root” cause is also problematic. Few injuries are caused by a single “root” cause, and are instead caused by multiple, inter-related causes and effects that grew gradually over time. In basic problem solving methodology, the first step in solving a problem is to categorize it as either broad, specific, decision or planning. Most injuries are caused by broad problems while most quality defects are caused by specific problems. I can’t think of an injury that is caused by a planning or decision problem (that doesn’t mean they don’t exist, but I am prepared to say they are exceedingly rare.) Once a problem is categorized the next step is to identify its structure; is it gradual, sudden, start-up, recurring, or positive? In safety, we tend to see injuries as being caused by specific conditions with a sudden structure. In some cases this is true, typically in mass production environments and where the worker is engaged in standard work. But in far more cases, injuries are caused by a broad problem with a gradual structure. In these cases, the situation continues to worsen until a threshold is reached and some catalyst is present that sets off a chain reaction. People tend to look at these types of injuries as “freak accidents” that could never have been predicted and they are right to some degree, because one cannot predict or prevent these incidents when one is using the wrong tools. Traditional root cause analysis focuses on identifying the one cause of an injury and tends to minimize contributing factors. This singular approach tends to cause a problem with a recurring structure to manifest. The reason for this is simple: by removing only one of the multiple, inter-related factors that contributed to the injury one raises the threshold at which an injury will occur. The problem seems to disappear but is actually lurking just below the surface. To use a medical analogy it masks the symptoms instead of curing the disease. Sooner or later the situation will again reach the threshold and cause another, perhaps more serious injury or fatality. We see this often in today’s workplace where organizations celebrate the achievement of zero-incidents, or extremely low incident rates only to later have a fatality (or multiple fatalities) catch them completely unaware. (Incidentally, if the organization would have approached the zero-injury, or acceptably low injury rate as a problem with a positive structure, and tried to understand the factors that caused this positive outcome, it could replicate the things that work in other locations and eliminate the things that its doing in the name of safety that are costing money but having no appreciable effect on safety.) This obsession with finding the root cause, before truly analyzing the situation and context of an injury seriously impedes our ability to create a workplace that has significantly less risk.

There is no denying that safety in the workplace has come a long way over the last 100 years, but I contend that much of that has to do with the Hawthorn Effect and picking low-hanging fruit. If we are to take worker safety to the next level, we have to rethink our focus and start focusing on the things that will have the greatest impact on worker safety.

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What Can The Hawthorne Electric Studies Teach Us About Worker Safety


By Phil La Duke

Last week I spoke at the National Safety Council where the behemoths of safety gather. I saw some really cool new products—work pants with need pads sewn into them, the latest in ceramic cutting technology, and even an amazing device that prevents industrial vehicle and pedestrian accidents—but I also heard a lot of the same old drivel some repackaged but mostly unadulterated snake oil sold in largely the same package, and a fair amount of the same old hackneyed arguments.  There isn’t much new under the sun, at least not in worker safety.

One of the supposed “tried and true” safety tactics is conducting behavior observations.  Behavior observations lie at the heart of many safety management systems. Exactly how these practices are performed can vary widely from organization to organization and the efficacy of these practices similarly varies from location to location.  I’ve remained largely silent (well as silent as I can ever be) on the practice, because I know many smart safety professionals for whom I have the utmost respect who value behavior observations as important components of their overall safety tactics and strategy.

The thinking that drives behavior observations is that a supervisor (or in some cases, another worker or a safety professional) watches a worker do his or her job after which the observer offers tips on how to do the work more safely. I’m over simplifying, but not a lot.  Proponents of the behavior observation believe that the combination of intervention in cases of unsafe behavior and positive feedback for safe behavior reduce injuries. Those that support Behavior Based Safety proudly point to their love of scientific study and organizational psychology but in doing so they ignore one of the most important studies of the workplace in history, those at the Hawthorne Western Electric Company (and other research conducted by conducted by Fredrick Taylor and others.) For five years, researchers studied the effects of physical, social, psychological, and environmental factors would influence the productivity[1] of workers.  The most famous finding was the dubbed the Hawthorne effect — which referred to an increase in worker productivity produced by the psychological stimulus of being made the focus of the study. One could easily extrapolate that workers too can be temporarily manipulated into working safely, but the results are neither lasting nor indicative of a lasting behavior change. If the Hawthorne Effect is true of safety, than it doesn’t matter whether the feedback is positive or negative, skilled or unskilled, well articulated or grunted out by a bonobo, the behavior of the worker will temporarily improve.

But there were other findings as well, researchers found lesser known phenomena, like the fact that research in and of itself alter the behaviors that are studied.  This phenomenon has been replicated many times in many other studies.

But perhaps more germane to safety, researchers concluded:

  • Productivity is a group activity. The Hawthorn researchers found that the relationship between the supervisors and the workers played an important role in workplace productivity. It should surprise no one that workers with good relationships with their supervisors will tend to report hazards more frequently.  If the worker believes his or her supervisors care about their safety they are far more inclined to bring safety concerns to the attention of leadership.
  • Team Norms Directly Influence Worker Productivity. Researchers have known for a hundred years that workers set the expectations for fair day’s work; but Hawthorn researchers were the first to demonstrate and describe this phenomenon. Similarly, work groups set the expectations of safety and safe work practices. This is the essential core of a corporate culture—that the work group set the rules, even those associated  with worker safety.
  • Worker skill is a poor predictors of his or her job performance. The Hawthorne study found that while worker capabilities provide some clues as to the future performance of a worker (in terms  of the physical and mental potential of the worker), exactly how well the worker will perform (again this applies to safety) the real performance is strongly influenced by social factors; it’s less about whether or not the worker is observed, and more about how the worker interacts with his or her peers.
  • The workplace is a social system. Fredrick Taylor and his colleagues viewed, the work place as a social construct; a system composed of many unpredictable and interdependent elements.

Beyond the Hawthorne Effect, proponents of behavior observations also ignore several key truths:

  • Workers behave differently when they are being studied. From the Hawthorne Electric studies in workplace productivity to studies with animals, researchers now know that the behavior of a research subject is significantly changed simply by the act of observing them.  The tale, it would seem, is tainted in the telling.
  • Observations are essentially shoddy training needs assessments.  In those cases where the worker is acting unsafely (or more likely less safely) the result is either that the worker is doing so because he or she needs to be trained in the correct procedures, or the worker has made an error.  Since we know that human error cannot be prevented through behavior observations, the act of observing workers is akin to doing a slip shod training needs assessment.

 Observations are expensive, pointless, and provide little information that could not be gathered more effectively through another method.  It is an overblown, quasi-scientific reaction to a problem that can be readily addressed through an easier and cheaper approach.


[1] It’s important to note, that while the Hawthorne researchers were studying productivity, it’s not that far from safety.  Safety is the product of a robust and efficient process; that is to say, a process cannot be considered efficient or productive if it produces poor quality or injures workers.  For the purposes of this post, productivity = safety.

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